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Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor.

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Presentation on theme: "Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor."— Presentation transcript:

1 Urethral Obstruction Jerry G. Blaivas, MD Clinical Professor of Urology Weil Cornell Medical College New York Presbyterian Medical Center Adjunct Professor of Urology SUNY Downstate Medical Center

2 Urethral Obstruction in Women Prevalence: 2 - 29% of women with persistent LUTS Symptoms: – storage 29% – emptying 8% – both 63%

3 Diagnosis Urodynamics (synchronous pdet / Q) Cystoscopy

4 Urethral obstruction High detrusor pressure (pdet > 20 cm H 2 0) Low uroflow (Qmax < 12 ml/S)

5 Impaired Detrusor Contractility Weak & or poorly sustained detrusor contraction (pdet < 20 cm H 2 0) Low flow (Qmax < 12 ml/S)

6 Blaivas - Groutz Nomogram

7 Diagnosis ”…radiographic evidence of obstruction…in the presence of a sustained detrusor contraction.” No specific UDS criteria Obstructed women had: –lower Qmax –higher Pdet@Qmax –higher PVR 23% of 331 women were obstructed Nitti et al., 1999:

8 Etiology Groutz et al., 2000; Nitti et al., 1999 Prior surgery 14 - 30% Prolapse 29% Stricture 15% 1 O bladder neck obstruction 10 - 16% DESD 6% Learned Voiding Dysfunction 6 - 33% Urethral diverticulum 4%

9 Urethral Obstruction in women Anatomic Functional

10 Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy

11 Functional Urethral Obstruction Primary vesical neck Neurogenic Acquired behavior

12 Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy

13 MSCO High pressure Low flow

14 Blaivas - Groutz Nomogram

15 Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Atrophy

16 Pdet @ Qmax = 36cm H2O Qmax = 8.3ml/S

17 Blaivas - Groutz Nomogram

18 Pdet @ Qmax = 54 cm H2O Qmax = 2 ml/S,

19 Blaivas - Groutz Nomogram

20 Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Atrophy

21 FS pdet@Qmax = 68 cm H 2 0 Qmax = 5 ml/S Tic

22 Blaivas - Groutz Nomogram

23 Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Atrophy

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25 Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy

26 JTJT JT pdet@Qmax = 80 cm H 2 0 Qmax = 5 ml/S

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28 Blaivas - Groutz Nomogram

29 Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy

30 JTJT JT pdet@Qmax = 75 cm H 2 0 Qmax = 8 ml/S Urethral obstruction

31 Blaivas - Groutz Nomogram

32 Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy

33

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35 Anatomic Urethral Obstruction Compression Post surgical Prolapse Urethral Diverticulum Tumor Urethral stricture Post surgical Traumatic Idiopathic Atrophy

36 RSN pdetmax = 90 cm H 2 0 Qmax = 7 ml/S

37 Blaivas - Groutz Nomogram

38 Anatomic Urethral Obstruction: Treatment Intermittent catheterization Surgery - depends on the cau se: –correct prolapse –sling incision / urethrolysis –urethral diverticulectomy

39 Surgical Rx of Stricture Urethral dilation Urethrotomy Urethroplasty

40 Buccal graft

41 Functional Urethral Obstruction Primary vesical neck Neurogenic Acquired behavior

42 2 Strss pdet@Qmax = 150 cm H20 Qmax = 1 ml/S

43 Blaivas - Groutz Nomogram

44 Functional Urethral Obstruction Primary vesical neck Neurogenic Acquired behavior

45 PS Involuntary detrusor contraction Involuntary sphincter contraction Obstruction due to sphincter contraction

46 CG Involuntary detrusor contraction Involuntary sphincter contraction Vesical neck obstruction

47 Blaivas - Groutz Nomogram

48 Functional Urethral Obstruction Primary vesical neck Neurogenic Acquired behavior

49 Detrusor contraction Sphincter contraction Low flow Obstruction by sphincter

50 Functional Urethral Obstruction: Treatment Primary vesical neck TUI / TUR of vesical neck ? Alpha adrenergic antagonists Neurogenic Intermittent catheterization +/- anticholinergics, Botox, Neuromodulation, enterocystoplasty Acquired behavior Bmod / biofeedback

51 Impaired Detrusor Contractility Low flow Weak or poorly sustained detrusor contraction Pressure flow criteria: –Qmax < 12 ml/s –Pdet@Qmax < 20 cm H2O –Wmax < 10 Groutz et al., 2000

52 amb pdetmax = 10 cm H 2 0) Qmax = 8 ml/S

53 Impaired Detrusor Contractility: Etiology Neurogenic –Thoracic, lumbar & sacral lesions –Diabetes mellitus Myogenic –Primary / idiopathc –Urethral obstruction –Bladder overdistension Urethral obstruction Post-surgical –Ischemia Groutz et al., 2000

54 Impaired Detrusor Contractility: Treatment Observation Double voiding Timed voiding Intermittent catheterization ? Medications –Cholinergic agonists –Alpha adrenergic antagonists Neuromodulation

55 Conclusion Urethral obstuction not uncommon Prevalence: 2 - 29% of pts with LUTS Symptoms – non-specific –irritative 29% –obstructive 8% –both 63% Diagnosis based on p/Q studies Rx based on underlying cause


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